PARQ Form

Please complete by your first scheduled session.

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to helping your trainer develop a program that addresses your needs, goals and interests and is safe and effective.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Phone Number*
Occupation
Emergency Contact:*

First NameLast Name
Relationship*
Phone Number*
Physician's Name*

First NameLast Name
Phone Number*

Pain and Injury Questions
Can you describe the location and intensity of your pain or discomfort?
Have you experienced any numbness, tingling, or weakness in the affected area?

YesNo
How long have you been experiencing this pain or discomfort?
On a scale of 0 to 10 (0 = no pain 10 = the worst pain imaginable), how would you rate your pain on an average day?
Does your pain interfere with your daily activities, such as work, exercise, or sleep?

YesNo
Are there any activities or movements that you currently avoid due to pain or discomfort? If so, please explain.
Have you noticed any specific triggers or patterns that worsen or alleviate your pain? If so, please explain.
Have you had any previous injuries or surgeries related to this issue? If so, please explain.
Have you had any recent X-rays, MRIs, or other diagnostic tests related to your condition?

YesNo
Have you tried physical therapy, acupuncture, chiropractic care, injections or any other form of therapy? If so, what was your experience like?

Fitness History
On a scale from 1-10, how would you rate your present fitness level (1=Worst 10=Best)?
Have you been exercising consistently for the past 3 months?

YesNo
When were you in the best shape of your life?
When did you first start thinking about getting in shape?
What, if anything stopped you in the past?

EXERSICE QUESTIONS

Skip to the next section if you are currently inactive.
If your participation is lower than you would like it to be, what are the reasons?

Lack of InterestIllness/InjuryLack of TimeOther
How often do you take part in physical exercise?

1-2x/week3-4x/week5-7x/week
How long have you been consistently physically active for?
What activities are you presently involved in?

Please complete by your first scheduled session.